If it seems like every day there’s a new study that changes everything you know about salt, or heart disease, or some other facet of human health, imagine being a doctor. Physicians don’t stop learning about the human body after medical school. They have to keep up with new information in their field — mandated legally, by state licensing requirements; professionally, by specialty certification boards; and ethically, by a culture that prioritizes patient wellbeing.

Okay, if you’re a meeting professional who works for a medical or health-care organization, it’s not actually a problem for you to imagine any of this. In fact, that’s more or less your job description. But the point is, those professional mandates have been known to evolve nearly as fast as medicine itself. The latest is maintenance of certification (MOC), which has changed the way physicians keep their board certifications in specialty areas. “Our audience is at least 90-percent physician,” said Joyce Paschall, CAE, CMP-HC, CMM, director of education and meetings for the American College of Occupational and Environmental Medicine (ACOEM), “so if we didn’t offer MOC [programs], we would be rather foolish.”

But what exactly is MOC, and where did it come from? How is it different from standard continuing medical education (CME)? We traced MOC back through the decades — from first introduction to physician response — and found out how Paschall and other meeting professionals have successfully added it to their conference offerings.

CASE HISTORY

Board certification in the United States dates back to 1917 and the country’s first medical-specialty board, the American Board of Ophthalmology. As medicine continued to advance and new specialties emerged, more boards appeared. A 2008 article in the journal of the American Clinical and Climatological Association describes this period as a time “when American medicine was beginning to try to distinguish itself from the proprietary physicians trained by apprenticeship, many of whom had little science base and were often considered ‘snake-oil salesmen.’”

At first, board certification was voluntary — an extra flourish for a doctor’s resume. Patients didn’t prioritize it, or often even know about it, and the certification process was straightforward. After their residencies, new doctors took an exam in their specialty area to affirm their expertise. Passing meant a lifelong certification from your specialty board — the American Board of Dermatology, or Pediatrics, or Anesthesiology, or any of the other professional bodies that soon emerged.

But starting in the 1970s, boards began to rethink how long those specialty certifications should last. They decided that physicians who passed a surgery exam at age 30, for example, should prove their knowledge again at some point in the next 50 years. A number of boards began placing time limits on their certifications and introduced recertification processes. Then, in 2000, the American Board of Medical Specialties (ABMS) announced that its 24 member boards — who collectively oversee 150 specialty and subspecialty areas of medicine — each had to require that doctors take a recertification exam every 10 years. ABMS soon incorporated other requirements, too, all of which fall under the heading “maintenance of certification.” (This is for allopathic physicians — that is, M.D.s. Osteopathic physicians, or D.O.s, have similar requirements called Osteopathic Continuous Certification that are administered by various specialty boards operating under the American Osteopathic Association.)“The simplest way I can think of explaining this,” said Patrick Alguire, M.D., senior vice president for medical education at the American College of Physicians, “is that MOC is a process to assure that physicians are keeping up in areas of medical knowledge and skills.”

But the specifics are more complicated. Doctors maintain their certification through what ABMS calls “continuous, specialty-specific learning, assessment, and improvement activities.” Individual MOC programs vary by specialty board, but must include “Lifelong Learning and Self-Assessment” (LLSA) activities. That’s where MOC programs come in — and, by extension, the meetings and conferences where those programs are offered. Doctors certified by the American Board of Internal Medicine (ABIM), for example, must complete at least one MOC activity every two years, earn 100 MOC points every five years, and pass an MOC recertification exam every 10 years. Meanwhile, the American Board of Emergency Medicine (ABEM) doesn’t have MOC points at all, but instead requires roughly 25 CME credits per year, four LLSA tests over the course of 10 years, and various other activities.

This is where things can get confusing: While specialty boards like ABIM and ABEM require CME credits as part of maintaining certification, MOC and CME aren’t completely interchangeable. That said, most states require that doctors earn CME credits to keep their medical licenses — and without a valid license, doctors can’t keep their specialty certifications, either. Like MOC, requirements for CME vary, but by state rather than by specialty board. Virginia-based doctors must earn 60 CME credits every two years, while in Washington state, it’s 200 credits every four years, and in New Mexico, 75 credits every three years.

‘A HOT-BUTTON TOPIC’

But all those acronyms — ABMS, CME, LLSA — only tell half the story, because it turns out that not everyone likes MOC. ABIM is the largest ABMS specialty board. Its MOC program “culminated a few years ago, when all the requirements were in place,” Alguire said. “That’s when people started to get really angry. This a hot-button topic among physicians.”

Judd Flesch, M.D., a pulmonologist at Penn Medicine in Philadelphia, remembers when ABIM rolled out a new wave of requirements in 2012. “People didn’t really understand what was happening or why,” Flesch said. “We were getting these emails saying, ‘We’re starting this program. You owe us $500.’ Everybody was a little confused by that. Then they released very complex requirements. Then people started trying to do [those requirements], and they were difficult to do.”

But MOC isn’t something doctors can ignore. Roughly 80 percent of U.S. physicians with active licenses are certified by an ABMS specialty board, according to an article in the Journal of Medical Regulation. Often, prominent health organizations won’t even hire a doctor who isn’t board-certified. Flesch said that Penn Medicine wouldn’t allow him to practice there if he didn’t maintain at least one board certification.

Lois Margaret Nora, M.D., J.D., ABMS’s president and CEO, said that board certification was created as a “quality indicator” to help patients, families, and communities choose their doctors. And requiring certain activities to maintain that certification means that board-certified physicians “are meeting very high standards for professionalism, for their knowledge, for their continuous learning, and for work they do to improve their own practice.”

Flesch agrees with the idea behind ABIM’s MOC program. “Most physicians these days think you shouldn’t be able to take one exam when you’re 30 years old and then be accredited by your specialty organization forever,” he said. “But the practice of MOC has been a major problem.”

First there are the certification exams themselves, which according to Flesch don’t always reflect the way doctors practice everyday medicine. “They’re multiple-choice,” he said, “and patients are not multiple-choice.” Then there are the activities required to earn MOC credits. Alguire said he’s heard many physicians describe that process as “burdensome,” with programs that may not be relevant to the type of medicine a doctor practices, or that duplicate things they’re already doing. And, Flesch added, many doctors resent the price tags attached to MOC programs. As a certified internist with two subspecialty certifications — pulmonary and critical care — it will cost him nearly $5,000 to maintain his certifications over the next 10 years. “People basically think it’s one big money-making racket for the certifying organization,” Flesch said.

Flesch certainly isn’t alone in these criticisms. Multiple online forums have sprung up to oppose MOC programs and call for change.A small sampling of comments on a website dedicated to reforming the board recertification process (official name: Change Board Recertification) includes: “MOC is, for lack of a better term, a farce that does not improve upon the existing continuing medical education system.” And: “As I complete my MOC this year, am just shocked at the time & expense. Much of the requirements are busy work — we have no time for that.” And: “I feel sorry for you younger doctors who will have to put up with this nonsense for your whole careers.”

In some cases, the objections have escalated to legal action. In April 2013, the Association of American Physicians and Surgeons (AAPS) filed a federal lawsuit against ABMS for “restraining trade and causing a reduction of access by patients to their physicians,” according to an AAPS statement. “In a case cited in this lawsuit,” the AAPS statement continued, “a first-rate physician in New Jersey was excluded from the medical staff at a hospital … simply because he had not paid for and spent time on recertification…. He runs a charity clinic that has logged more than 30,000 visits, but now none of those patients can see him at the local hospital because of the money-making scheme of recertification.” AAPS’s lawsuit is still pending.

Specialty boards are working to address physician complaints about MOC. ABIM issued a statement in February 2015 that began: “ABIM clearly got it wrong.” It continued: “We launched programs that weren’t ready and we didn’t deliver an MOC program that physicians found meaningful. We want to change that.” ABIM announced that some of itsnew MOC requirements would be postponed for at least two years, that its MOC exam would be “more reflective of what physicians in practice are doing,” and that its MOC enrollment fees would not increase until at least 2017.

ABIM also partnered with the Accreditation Council for Continuing Medical Education (ACCME) last year to better align CME and MOC credits. As a result, many educational activities — including approved conference sessions — now can earn both CME credits and MOC points. “I think now that there’s been so much public outcry,” Flesch said, “it’s gone from a state of confusion, to frustration, to actively organizing to improve it.”

No one is more aware of that confusion than ABMS. “Physicians and others are under enormous stress right now with all the changes that are happening in the health-care system and the like,” Nora said. “And there has been pushback about maintenance of certification. Some of that pushback I think just reflects people’s general frustration. But some of it has been people saying, ‘Wow, you should recognize this,’ or ‘You should change your program in a particular way.’ And actually, our boards have been very responsive to that. We want a rigorous program, because we exist for the patients, families, and communities that are relying on our certificate in their choice of doctor and the like. So we want it to be rigorous, but we also want it to be user-friendly and meaningful to the physician.”

EARLY ADAPTERS

With many physicians’ board certifications riding on MOC activities, medical conferences are incorporating MOC credit-bearing sessions for attendees. The American Thoracic Society (ATS) hosts its International Conference every May. According to Chief Program Officer Eileen Larsson, 13,697 people attended this year. Slightly more than half were from the United States, and many needed MOC points. Shortly after ABIM announced changes to its MOC requirements for 2012 — including a shorter time frame to earn the necessary points — ATS introduced a pilot MOC program at its conference. “We realized there would be an increased demand for medical-knowledge modules,” Larsson said, “and that this was an opportunity to make sure we supported our members” who needed MOC points.

The only problem was that ATS had already set its agenda for the 2012 conference. It was too late to develop specific MOC sessions, so instead ATS identified an existing module in pulmonary medicine and created MOC questions related to it. About 190 attendees completed the module and received MOC points. “The pilot confirmed our attendees’ interest,” Larsson said, “and also confirmed that we could adapt our conference to support this format.”

In 2013, ATS rolled out sessions specifically related to MOC. Its Education Committee wrote the questions, and together with its International Conference Committee developed a three-year cycle for MOC content. By 2014, the number of attendees taking MOC assessments doubled.Today, if ATS attendees want to earn ABIM-approved MOC points from a conference session, they have to pass an online post-test administered through ATS’s website. Larsson said ATS makes sure the test questions are covered in its MOC sessions.

The MOC tests have an added benefit for ATS. They let the society track how much people are learning in specific sessions. Larsson said that in 2014, medical knowledge increased 34 percent between the pre- and post-tests for MOC sessions. “Each year,” she said, “we’re able to show a significant improvement of medical knowledge from people that take those MOC courses.”

[pullquote class=”pullright”]Starting in the 1970s, boards began to rethink how long specialty certifications should last.[/pullquote]

And not everyone is showing up just for the MOC credit. In the last two years, 1,413 ATS International Conference attendees have taken an MOC post-test, and 1,354 have passed. But just 1,042 doctors claimed the MOC points. That means roughly 300 people just wanted to see if they could do it. “They were curious,” Larsson said. It also means attendees are finding ATS’s MOC sessions worthwhile whether or not they need the points. “I think it made our conference a very valuable resource,” Larsson said.

Indeed, attendance at the conference has gone up by about 5,000 people over the last five years, according to Larsson. She quickly added that MOC is “a contributing factor, … but I think there are many others, too.”

LEVERAGING TECHNOLOGY

In late 2015, ABIM announced a significant change to its MOC process. Through a partnership with ACCME, it would expand the number of CME activities that also carry MOC points and, according to ACCME’s website, “streamline the process for registering CME activities in ABIM’s MOC program.” In other words, the change makes it easier for medical societies who serve ABIM-certified doctors and already offer CME programming at their annual meetings to now grant MOC points for the same activities.

The Heart Rhythm Society (HRS) saw exactly that opportunity, according to Chloé Thomas, HRS’s director of scientific sessions and education. Attendees had often asked why HRS wasn’t incorporating MOC into its Annual Scientific Sessions, about two-thirds of whose 7,000-plus participants are physicians. “The [MOC] process was a lot different when it was strictly with ABIM,” Thomas said, “and we really did not have the resources to explore that. When ABIM and ACCME launched their collaboration last fall, it opened up doors for us.”

According to Thomas, Tracy Blithe, CMP, HRS’s manager of CME programs and meeting operations, challenged her team to think creatively about featuring MOC programming at the 2016 Scientific Sessions, held in San Francisco this past May. In response, HRS offered MOC points for the first time this year — and modified its existing technology to do it. HRS uses the OASIS platform from CTI Meeting Technology to manage its speaker invitations, abstract submissions, and CME offerings. It worked with CTI to repurpose those tools for pre- and post-tests at MOC sessions. As a result, HRS can collect MOC questions, answers, rationale, references, and images electronically.

This year’s MOC-point-granting sessions included “Athletes, Arrhythmias, and the Risk of Sudden Death,” “Why, When, and How to Implement Remote Monitoring of Cardiac Implantable Electronic Devices,” and “The Science Behind the Sudden-Death Investigation.” All told, HRS offered MOC points at 16 sessions. And while it’s too soon to know whether MOC programming is affecting attendance, Thomas thinks there may be a bump in next year’s numbers. “I think it’s worth the investment,” she said. “It’s something very unique you can add to your portfolio — especially if you have the technology that we’re using.”

But even without special technology, medical organizations are figuring out how to help their attendees earn MOC credit. ACOEM sessions “almost always” carry both CME and MOC credit — including at the organization’s annual American Occupational Health Conference, according to Paschall. (ACOEM doctors receive certification from the American Board of Preventive Medicine [ABPM], which requires 250 CME credits every 10 years, 100 of which must be MOC-approved.) At this year’s conference, held in Chicago in April, every session offered MOC credit. To receive it, physicians were required to complete a self-assessment — three questions for each hour’s worth of MOC content — which ACOEM passed along to ABPM. Those questions came from the speakers, who sent them to Paschall along with their bios and audiovisual needs.

It can be complex to keep track of everything, so Paschall has a staff member whose job is to manage all CME and MOC processes, among other things. “You need to have internal assignments,” Paschall said, “an understanding of what needs to be done, and a point person to do it.”

MEETINGS AS MEDIATORS

Along with delivering MOC programming to attendees who need it, ABMS’s Nora identified another role that meetings can play. Acknowledging the disagreements that have erupted around MOC programs, she noted that some medical organizations have brought in specialty-board reps to talk about their programs and solicit feedback at annual meetings. At ATS’s 2016 International Conference, for example, ABIM held six focus-group-style “discovery sessions,” in which they discussed the MOC program and, according to Larsson, “how to make it work better for physicians.” Nora said: “In addition to the very important educational functions that are happening in those meetings, there’s also a quality-improvement function that the boards have taken advantage of and used them for.”

A neurologist by training, Nora is a faithful attendee of her own specialty and subspecialty society events, including the American Academy of Neurology’s Annual Meeting, and emphasized the value of medical conferences “in a day when so much is becoming online.” She added: “I think it just has to be reinforced how important those annual meetings are [for physicians] as a professional home, a place to network, a place to learn.”

And maybe a place to check off some MOC credit, too.

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